“You have got to get it right up front,” Greg Maynard, MD, UCSD, told hospitalists at SHM's HM14 annual meeting when discussing how to leverage the electronic health record (EHR) to perform active surveillance for quality and safety deficits. “This method can be labor intensive up front, but [it] leverages the EHR and has the potential to disseminate improvement efficiently,” Dr. Maynard said. He went on to provide many specific tips and techniques for providers to use in order to design successful clinical decision support strategies.

Key Points

•  You need to be willing to redesign the system to go beyond current process measures to achieve optimal care. Currently, there can be a poor association between process measures and outcomes measures;

• You need real-time data to be able to perform a “measure-vention,” or measurement with concurrent intervention. You need to be able to collect data and then act on it for a particular patient that day;

• You need to determine who is going to act on the quality or safety deficits that are discovered once you develop measure-ventions, or real-time measures. There needs to be someone tasked with reviewing and acting on these daily reports; and

• Some institutions have developed “dynamic dashboards” that highlight active, ongoing surveillance of multiple quality improvement metrics. These help to create shared situational awareness for all providers involved in a patient’s care.

 

James O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.

“You have got to get it right up front,” Greg Maynard, MD, UCSD, told hospitalists at SHM's HM14 annual meeting when discussing how to leverage the electronic health record (EHR) to perform active surveillance for quality and safety deficits. “This method can be labor intensive up front, but [it] leverages the EHR and has the potential to disseminate improvement efficiently,” Dr. Maynard said. He went on to provide many specific tips and techniques for providers to use in order to design successful clinical decision support strategies.

Key Points

•  You need to be willing to redesign the system to go beyond current process measures to achieve optimal care. Currently, there can be a poor association between process measures and outcomes measures;

• You need real-time data to be able to perform a “measure-vention,” or measurement with concurrent intervention. You need to be able to collect data and then act on it for a particular patient that day;

• You need to determine who is going to act on the quality or safety deficits that are discovered once you develop measure-ventions, or real-time measures. There needs to be someone tasked with reviewing and acting on these daily reports; and

• Some institutions have developed “dynamic dashboards” that highlight active, ongoing surveillance of multiple quality improvement metrics. These help to create shared situational awareness for all providers involved in a patient’s care.

 

James O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.

“You have got to get it right up front,” Greg Maynard, MD, UCSD, told hospitalists at SHM's HM14 annual meeting when discussing how to leverage the electronic health record (EHR) to perform active surveillance for quality and safety deficits. “This method can be labor intensive up front, but [it] leverages the EHR and has the potential to disseminate improvement efficiently,” Dr. Maynard said. He went on to provide many specific tips and techniques for providers to use in order to design successful clinical decision support strategies.

Key Points

•  You need to be willing to redesign the system to go beyond current process measures to achieve optimal care. Currently, there can be a poor association between process measures and outcomes measures;

• You need real-time data to be able to perform a “measure-vention,” or measurement with concurrent intervention. You need to be able to collect data and then act on it for a particular patient that day;

• You need to determine who is going to act on the quality or safety deficits that are discovered once you develop measure-ventions, or real-time measures. There needs to be someone tasked with reviewing and acting on these daily reports; and

• Some institutions have developed “dynamic dashboards” that highlight active, ongoing surveillance of multiple quality improvement metrics. These help to create shared situational awareness for all providers involved in a patient’s care.

 

James O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.

Presenters: Todd Kislak, MBA, Brian Hazen, MD, Troy Ahlstrom, MD

Summation: Two hospitalist group directors shared their scheduling tools and philosophies regarding optimal scheduling options. Dr. Hazen does the scheduling himself and Dr. Ahlstrom uses a web-based scheduling program. They both acknowledged that provider retention and satisfaction are tightly wrapped up in how you schedule providers. They recommend that groups accommodate individual preference but also be fair and equitable to the entire group.

Key Takeaways

Dr. Hazen recommended:

• Find good providers first and then try to determine their desires and fit that into the schedule as best as possible.
• Protect your nocturnists- they burn out easily and provide a key service to the hospital and your group.
• Find each person's strengths and try to cater to those to make them most successful.
• Design a weighting (or point system) for various shifts and ensure equality by using that system.
• The last day on service is a day focused on "discharges" and other patients begin with a new provider coming on service (ensures continuity and lowers LOS).

Dr. Ahlstrom recommended:

• Block schedules are hard to make flexible and do not always fit with the flux of patient loads and urgent needs of the group.
• Designing and managing the schedule is a costly endeavor and they shifted this from a physician duty to an administrator's duty. They used the Lightning Bolt solution and have enjoyed significant savings and profit.
• The ROI is made up of increased encounters, increased provider retention, and decreased locums usage.

Greg Harlan is a pediatric hospitalist, medical director for IPC The Hospitalist Company, and a member of Team Hospitalist.

Presenters: Todd Kislak, MBA, Brian Hazen, MD, Troy Ahlstrom, MD

Summation: Two hospitalist group directors shared their scheduling tools and philosophies regarding optimal scheduling options. Dr. Hazen does the scheduling himself and Dr. Ahlstrom uses a web-based scheduling program. They both acknowledged that provider retention and satisfaction are tightly wrapped up in how you schedule providers. They recommend that groups accommodate individual preference but also be fair and equitable to the entire group.

Key Takeaways

Dr. Hazen recommended:

• Find good providers first and then try to determine their desires and fit that into the schedule as best as possible.
• Protect your nocturnists- they burn out easily and provide a key service to the hospital and your group.
• Find each person's strengths and try to cater to those to make them most successful.
• Design a weighting (or point system) for various shifts and ensure equality by using that system.
• The last day on service is a day focused on "discharges" and other patients begin with a new provider coming on service (ensures continuity and lowers LOS).

Dr. Ahlstrom recommended:

• Block schedules are hard to make flexible and do not always fit with the flux of patient loads and urgent needs of the group.
• Designing and managing the schedule is a costly endeavor and they shifted this from a physician duty to an administrator's duty. They used the Lightning Bolt solution and have enjoyed significant savings and profit.
• The ROI is made up of increased encounters, increased provider retention, and decreased locums usage.

Greg Harlan is a pediatric hospitalist, medical director for IPC The Hospitalist Company, and a member of Team Hospitalist.

Presenters: Todd Kislak, MBA, Brian Hazen, MD, Troy Ahlstrom, MD

Summation: Two hospitalist group directors shared their scheduling tools and philosophies regarding optimal scheduling options. Dr. Hazen does the scheduling himself and Dr. Ahlstrom uses a web-based scheduling program. They both acknowledged that provider retention and satisfaction are tightly wrapped up in how you schedule providers. They recommend that groups accommodate individual preference but also be fair and equitable to the entire group.

Key Takeaways

Dr. Hazen recommended:

• Find good providers first and then try to determine their desires and fit that into the schedule as best as possible.
• Protect your nocturnists- they burn out easily and provide a key service to the hospital and your group.
• Find each person's strengths and try to cater to those to make them most successful.
• Design a weighting (or point system) for various shifts and ensure equality by using that system.
• The last day on service is a day focused on "discharges" and other patients begin with a new provider coming on service (ensures continuity and lowers LOS).

Dr. Ahlstrom recommended:

• Block schedules are hard to make flexible and do not always fit with the flux of patient loads and urgent needs of the group.
• Designing and managing the schedule is a costly endeavor and they shifted this from a physician duty to an administrator's duty. They used the Lightning Bolt solution and have enjoyed significant savings and profit.
• The ROI is made up of increased encounters, increased provider retention, and decreased locums usage.

Greg Harlan is a pediatric hospitalist, medical director for IPC The Hospitalist Company, and a member of Team Hospitalist.

LAS VEGAS—For three hospitalists at SHM's annual meeting at the Mandalay Bay Resort and Casino, today will be a masterful day. Patrick Conway, MD, MSc, FAAP, MHM, Steven Pantilat, MD, MHM, and Jack Percelay, MD, MPH, MHM, will be designated Masters in Hospital Medicine (MHM), the growing cadre of hospitalists who have attained SHM’s highest rank. Sixteen hospitalists have attained the MHM designation. The 2014 designees will be honored on stage today during ceremonies that include the announcement of all of SHM’s new fellows and SHM’s Annual Awards of Excellence.

"If you look at the previous MHM recipients, you see the pantheon of hospital medicine—an incredible group of individuals committed to improving the healthcare system and the care of patients," Dr. Pantilat wrote in an email to The Hospitalist eWire. "This designation recognizes that there are people who have made tremendous contributions to the field, and to changing the way we care for patients."

Dr. Pantilat, who was also a member of the inaugural class of Senior Fellows in Hospital Medicine (SFHM), is a professor of medicine in the department of medicine at the University of California at San Francisco (UCSF). He’s the founding director of the UCSF Palliative Care Program and serves as director of its Leadership Center, which trains hospitalists nationwide about how to establish palliative-care services. He is also a former SHM board member and the first recipient of the SHM Excellence in Teaching Award.

"I've never been a master of anything and despite my increasing age, somehow still feel too young to be a master," Dr. Pantilat adds. "Being bestowed with this highest honor in hospital medicine definitely ranks at the top."

Dr. Conway is used to being honored, but he says he still is humbled by the designation. As a former chairman of SHM's Public Policy Committee and the current chief medical officer for the Centers for Medicare & Medicaid Services (CMS) and its deputy administrator for innovation and quality, Dr. Conway is well known—and lauded—for giving HM a voice in Washington, D.C. He views his MHM as the latest sign that his specialty continues to grow and spur positive change in health-care delivery.

"I think the designation demonstrates that hospital medicine is a maturing specialty with strong leaders," he wrote in an email. "In addition, when you look at the current and former masters…it is a stellar group of leaders who are not only advancing hospital medicine, but also changing the face of health care across our nation and improving our health system."

Dr. Percelay is so humbled that he brought his wife, daughter, and mother with him to celebrate the moment. He’s also particularly honored that he and Dr. Conway represent the field of pediatric HM, which he believes has grown tremendously in reputation over the course of his career.

"We've been able to build upon the successes of adult hospital medicine and nurture the inherent 'playing nice in the sandbox' attitude of pediatrics to grow the discipline and work force to the point it's at now where pediatric hospitalists are seen as the experts and innovators for high value pediatric inpatient care," he wrote in an email.

Dr. Percelay is a hospitalist in the pediatric ICU at Saint Barnabas Medical Center in Livingston, N.J., and teaches in the department of physician studies at Pace University of College of Health Professions in New York. He was the founding chairman for the American Academy of Pediatrics Section on Hospital Medicine, an SHM board member from 2005 to 2012, and an associate editor of the Journal of Hospital Medicine. He says attaining the rank of master ranks just behind “being my daughter's father" on his list of personal accomplishments.

 

"I've received scholarships in high school, college, and medical school, but those acknowledged at most four years of work," he writes. "This award recognizes 20-plus years of work practicing as a pediatric hospitalist in community settings, caring for children and their families, and contributing to the field as a whole."

LAS VEGAS—For three hospitalists at SHM's annual meeting at the Mandalay Bay Resort and Casino, today will be a masterful day. Patrick Conway, MD, MSc, FAAP, MHM, Steven Pantilat, MD, MHM, and Jack Percelay, MD, MPH, MHM, will be designated Masters in Hospital Medicine (MHM), the growing cadre of hospitalists who have attained SHM’s highest rank. Sixteen hospitalists have attained the MHM designation. The 2014 designees will be honored on stage today during ceremonies that include the announcement of all of SHM’s new fellows and SHM’s Annual Awards of Excellence.

"If you look at the previous MHM recipients, you see the pantheon of hospital medicine—an incredible group of individuals committed to improving the healthcare system and the care of patients," Dr. Pantilat wrote in an email to The Hospitalist eWire. "This designation recognizes that there are people who have made tremendous contributions to the field, and to changing the way we care for patients."

Dr. Pantilat, who was also a member of the inaugural class of Senior Fellows in Hospital Medicine (SFHM), is a professor of medicine in the department of medicine at the University of California at San Francisco (UCSF). He’s the founding director of the UCSF Palliative Care Program and serves as director of its Leadership Center, which trains hospitalists nationwide about how to establish palliative-care services. He is also a former SHM board member and the first recipient of the SHM Excellence in Teaching Award.

"I've never been a master of anything and despite my increasing age, somehow still feel too young to be a master," Dr. Pantilat adds. "Being bestowed with this highest honor in hospital medicine definitely ranks at the top."

Dr. Conway is used to being honored, but he says he still is humbled by the designation. As a former chairman of SHM's Public Policy Committee and the current chief medical officer for the Centers for Medicare & Medicaid Services (CMS) and its deputy administrator for innovation and quality, Dr. Conway is well known—and lauded—for giving HM a voice in Washington, D.C. He views his MHM as the latest sign that his specialty continues to grow and spur positive change in health-care delivery.

"I think the designation demonstrates that hospital medicine is a maturing specialty with strong leaders," he wrote in an email. "In addition, when you look at the current and former masters…it is a stellar group of leaders who are not only advancing hospital medicine, but also changing the face of health care across our nation and improving our health system."

Dr. Percelay is so humbled that he brought his wife, daughter, and mother with him to celebrate the moment. He’s also particularly honored that he and Dr. Conway represent the field of pediatric HM, which he believes has grown tremendously in reputation over the course of his career.

"We've been able to build upon the successes of adult hospital medicine and nurture the inherent 'playing nice in the sandbox' attitude of pediatrics to grow the discipline and work force to the point it's at now where pediatric hospitalists are seen as the experts and innovators for high value pediatric inpatient care," he wrote in an email.

Dr. Percelay is a hospitalist in the pediatric ICU at Saint Barnabas Medical Center in Livingston, N.J., and teaches in the department of physician studies at Pace University of College of Health Professions in New York. He was the founding chairman for the American Academy of Pediatrics Section on Hospital Medicine, an SHM board member from 2005 to 2012, and an associate editor of the Journal of Hospital Medicine. He says attaining the rank of master ranks just behind “being my daughter's father" on his list of personal accomplishments.

 

"I've received scholarships in high school, college, and medical school, but those acknowledged at most four years of work," he writes. "This award recognizes 20-plus years of work practicing as a pediatric hospitalist in community settings, caring for children and their families, and contributing to the field as a whole."

LAS VEGAS—For three hospitalists at SHM's annual meeting at the Mandalay Bay Resort and Casino, today will be a masterful day. Patrick Conway, MD, MSc, FAAP, MHM, Steven Pantilat, MD, MHM, and Jack Percelay, MD, MPH, MHM, will be designated Masters in Hospital Medicine (MHM), the growing cadre of hospitalists who have attained SHM’s highest rank. Sixteen hospitalists have attained the MHM designation. The 2014 designees will be honored on stage today during ceremonies that include the announcement of all of SHM’s new fellows and SHM’s Annual Awards of Excellence.

"If you look at the previous MHM recipients, you see the pantheon of hospital medicine—an incredible group of individuals committed to improving the healthcare system and the care of patients," Dr. Pantilat wrote in an email to The Hospitalist eWire. "This designation recognizes that there are people who have made tremendous contributions to the field, and to changing the way we care for patients."

Dr. Pantilat, who was also a member of the inaugural class of Senior Fellows in Hospital Medicine (SFHM), is a professor of medicine in the department of medicine at the University of California at San Francisco (UCSF). He’s the founding director of the UCSF Palliative Care Program and serves as director of its Leadership Center, which trains hospitalists nationwide about how to establish palliative-care services. He is also a former SHM board member and the first recipient of the SHM Excellence in Teaching Award.

"I've never been a master of anything and despite my increasing age, somehow still feel too young to be a master," Dr. Pantilat adds. "Being bestowed with this highest honor in hospital medicine definitely ranks at the top."

Dr. Conway is used to being honored, but he says he still is humbled by the designation. As a former chairman of SHM's Public Policy Committee and the current chief medical officer for the Centers for Medicare & Medicaid Services (CMS) and its deputy administrator for innovation and quality, Dr. Conway is well known—and lauded—for giving HM a voice in Washington, D.C. He views his MHM as the latest sign that his specialty continues to grow and spur positive change in health-care delivery.

"I think the designation demonstrates that hospital medicine is a maturing specialty with strong leaders," he wrote in an email. "In addition, when you look at the current and former masters…it is a stellar group of leaders who are not only advancing hospital medicine, but also changing the face of health care across our nation and improving our health system."

Dr. Percelay is so humbled that he brought his wife, daughter, and mother with him to celebrate the moment. He’s also particularly honored that he and Dr. Conway represent the field of pediatric HM, which he believes has grown tremendously in reputation over the course of his career.

"We've been able to build upon the successes of adult hospital medicine and nurture the inherent 'playing nice in the sandbox' attitude of pediatrics to grow the discipline and work force to the point it's at now where pediatric hospitalists are seen as the experts and innovators for high value pediatric inpatient care," he wrote in an email.

Dr. Percelay is a hospitalist in the pediatric ICU at Saint Barnabas Medical Center in Livingston, N.J., and teaches in the department of physician studies at Pace University of College of Health Professions in New York. He was the founding chairman for the American Academy of Pediatrics Section on Hospital Medicine, an SHM board member from 2005 to 2012, and an associate editor of the Journal of Hospital Medicine. He says attaining the rank of master ranks just behind “being my daughter's father" on his list of personal accomplishments.

 

"I've received scholarships in high school, college, and medical school, but those acknowledged at most four years of work," he writes. "This award recognizes 20-plus years of work practicing as a pediatric hospitalist in community settings, caring for children and their families, and contributing to the field as a whole."

LAS VEGAS—Hospitalists are poised to be industry leaders and change agents as the rigmarole of healthcare reform shakes out over the next few years, a keynote speaker told a standing-room-only crowd Tuesday at HM14.

Ian Morrison, PhD, a founding partner of Strategic Health Perspectives, a forecasting service for the health-care industry that includes joint-venture partners Harris Interactive and the Harvard School of Public Health’s department of health policy and management, says that while the Affordable Care Act struggled with the rollout of its health exchanges, the broader movement from fee-for-service payment structures to population-based has "turned the corner…and we ain’t going back."

"You, as a society, you, as a group, need to take the long view," Dr. Morrison told 3,500 hospitalists at the Mandalay Bay Resort and Casino. "You are going to be central to this transformation."

Morrison, a native of Scotland whose delivery is half stand-up comic, half policy wonk, says hospitalists will be on the front lines as health care shifts from local health systems to just 100 to 200 regional or super-regional systems.

And while politicians and pundits dicker over how a generational shift in policies will be implemented, hospitalists will be the ones balancing that change with patients' needs.

"This is the work of the future," Morrison says. "And it is not policy wonk work; it is clinical work. It is about the transformation of the delivery system. That is the central challenge of the future. We've got to integrate across the continuum of care, using all the innovation that both public and private sectors can deliver.

"This is not going to be determined by CMS, in my view, but by the kind of innovation that America is always good at."

LAS VEGAS—Hospitalists are poised to be industry leaders and change agents as the rigmarole of healthcare reform shakes out over the next few years, a keynote speaker told a standing-room-only crowd Tuesday at HM14.

Ian Morrison, PhD, a founding partner of Strategic Health Perspectives, a forecasting service for the health-care industry that includes joint-venture partners Harris Interactive and the Harvard School of Public Health’s department of health policy and management, says that while the Affordable Care Act struggled with the rollout of its health exchanges, the broader movement from fee-for-service payment structures to population-based has "turned the corner…and we ain’t going back."

"You, as a society, you, as a group, need to take the long view," Dr. Morrison told 3,500 hospitalists at the Mandalay Bay Resort and Casino. "You are going to be central to this transformation."

Morrison, a native of Scotland whose delivery is half stand-up comic, half policy wonk, says hospitalists will be on the front lines as health care shifts from local health systems to just 100 to 200 regional or super-regional systems.

And while politicians and pundits dicker over how a generational shift in policies will be implemented, hospitalists will be the ones balancing that change with patients' needs.

"This is the work of the future," Morrison says. "And it is not policy wonk work; it is clinical work. It is about the transformation of the delivery system. That is the central challenge of the future. We've got to integrate across the continuum of care, using all the innovation that both public and private sectors can deliver.

"This is not going to be determined by CMS, in my view, but by the kind of innovation that America is always good at."

LAS VEGAS—Hospitalists are poised to be industry leaders and change agents as the rigmarole of healthcare reform shakes out over the next few years, a keynote speaker told a standing-room-only crowd Tuesday at HM14.

Ian Morrison, PhD, a founding partner of Strategic Health Perspectives, a forecasting service for the health-care industry that includes joint-venture partners Harris Interactive and the Harvard School of Public Health’s department of health policy and management, says that while the Affordable Care Act struggled with the rollout of its health exchanges, the broader movement from fee-for-service payment structures to population-based has "turned the corner…and we ain’t going back."

"You, as a society, you, as a group, need to take the long view," Dr. Morrison told 3,500 hospitalists at the Mandalay Bay Resort and Casino. "You are going to be central to this transformation."

Morrison, a native of Scotland whose delivery is half stand-up comic, half policy wonk, says hospitalists will be on the front lines as health care shifts from local health systems to just 100 to 200 regional or super-regional systems.

And while politicians and pundits dicker over how a generational shift in policies will be implemented, hospitalists will be the ones balancing that change with patients' needs.

"This is the work of the future," Morrison says. "And it is not policy wonk work; it is clinical work. It is about the transformation of the delivery system. That is the central challenge of the future. We've got to integrate across the continuum of care, using all the innovation that both public and private sectors can deliver.

"This is not going to be determined by CMS, in my view, but by the kind of innovation that America is always good at."

Presenter: Daniela Kroshinsky, MD, MPH

Summation: Cellulitis accounts for up to 10% of infectious disease hospitalizations and for about 3 billion/year in healthcare costs for both inpatient and outpatient treatment. Dr. Kroshinsky pointed out that dependent on patient factors, inadequately treated or recurrent cellulitis can lead to significant complications with chronic stasis changes and ulcerations. The diagnosis of cellulitis is typically made on physical exam. Cellulitis may have unusual presentations and at times the diagnosis can be difficult.

Hospitalists need to be aware that cellulitis has multiple mimics, and between 28% to 33% of patients are misdiagnosed as having cellulitis.

Dr. Kroshinsky listed a number of differential diagnoses. Frequent alternative diagnoses are dermatitis due to venous stasis or caused by lymphedema. Other skin conditions that need to be considered include erysipeloid, erythema migrans, atypical zoster, tinea and other fungal infections as well as skin changes caused by underlying malignancies.

Key Takeaways

• The diagnosis of cellulitis has a high error rate
• It is important to treat cellulitis adequately to prevent chronic skin changes and ulcers
• If cellulitis does not respond to appropriate antibacterial treatment, consider alternative diagnoses
• Be aware that many skin conditions can mimic cellulitis in immunocompromised patients

Klaus Suehler is a hospitalist at Mercy Hospital at Allina Health in Coon Rapids, Minn., and a member of Team Hospitalist.

Presenter: Daniela Kroshinsky, MD, MPH

Summation: Cellulitis accounts for up to 10% of infectious disease hospitalizations and for about 3 billion/year in healthcare costs for both inpatient and outpatient treatment. Dr. Kroshinsky pointed out that dependent on patient factors, inadequately treated or recurrent cellulitis can lead to significant complications with chronic stasis changes and ulcerations. The diagnosis of cellulitis is typically made on physical exam. Cellulitis may have unusual presentations and at times the diagnosis can be difficult.

Hospitalists need to be aware that cellulitis has multiple mimics, and between 28% to 33% of patients are misdiagnosed as having cellulitis.

Dr. Kroshinsky listed a number of differential diagnoses. Frequent alternative diagnoses are dermatitis due to venous stasis or caused by lymphedema. Other skin conditions that need to be considered include erysipeloid, erythema migrans, atypical zoster, tinea and other fungal infections as well as skin changes caused by underlying malignancies.

Key Takeaways

• The diagnosis of cellulitis has a high error rate
• It is important to treat cellulitis adequately to prevent chronic skin changes and ulcers
• If cellulitis does not respond to appropriate antibacterial treatment, consider alternative diagnoses
• Be aware that many skin conditions can mimic cellulitis in immunocompromised patients

Klaus Suehler is a hospitalist at Mercy Hospital at Allina Health in Coon Rapids, Minn., and a member of Team Hospitalist.

Presenter: Daniela Kroshinsky, MD, MPH

Summation: Cellulitis accounts for up to 10% of infectious disease hospitalizations and for about 3 billion/year in healthcare costs for both inpatient and outpatient treatment. Dr. Kroshinsky pointed out that dependent on patient factors, inadequately treated or recurrent cellulitis can lead to significant complications with chronic stasis changes and ulcerations. The diagnosis of cellulitis is typically made on physical exam. Cellulitis may have unusual presentations and at times the diagnosis can be difficult.

Hospitalists need to be aware that cellulitis has multiple mimics, and between 28% to 33% of patients are misdiagnosed as having cellulitis.

Dr. Kroshinsky listed a number of differential diagnoses. Frequent alternative diagnoses are dermatitis due to venous stasis or caused by lymphedema. Other skin conditions that need to be considered include erysipeloid, erythema migrans, atypical zoster, tinea and other fungal infections as well as skin changes caused by underlying malignancies.

Key Takeaways

• The diagnosis of cellulitis has a high error rate
• It is important to treat cellulitis adequately to prevent chronic skin changes and ulcers
• If cellulitis does not respond to appropriate antibacterial treatment, consider alternative diagnoses
• Be aware that many skin conditions can mimic cellulitis in immunocompromised patients

Klaus Suehler is a hospitalist at Mercy Hospital at Allina Health in Coon Rapids, Minn., and a member of Team Hospitalist.

A Scot who describes himself as a “professional futurist,” Ian Morrison, MD, helped HM14 get off to a start with laughter. Describing the background of the changes leading to the Affordable Care Act (ACA), Dr. Morrison repeated his key point several times: “We’ve got to change the delivery system.”

This overview is very timely as the deadline for enrollment to comply with the Affordable Care Act is March 31, 2014. Dr. Morrison cited that as of March 11, more than five million Americans have enrolled in exchanges and over 80% of them have paid premiums. Up to 14 million Americans are eligible for Medicaid expansion programs. It is unknown how many of these people were previously uninsured.

Dr. Morrison described several key current issues, including:

1. There are “two Americas”—those states expanding Medicaid and those states declining any expansion;

2. The ACA is the “the Law of the Land.” The difficult task is now implementing this large change in the industry;

3. Accountable Care is a megatrend, but accountable care organizations may not continue in the form they are now;

4. Pressure on costs and delivering value is intensifying;

5. Medicare is still a major part of the healthcare system. “Learning to live in Medicare” means taking out 10% to 20% of costs; and

6. There is a renewed focus on primary care.

Dr. Morrison shared a vision of the future as these trends continue. There will continue to be “massive consolidation” in which there may be only 100-200 large regional healthcare systems in the U.S. Related to this linked care, clinical protocols will be more widely used. Care coordination of transitions will be at a premium. The transition of moving away from hospital admissions to more home care will be economically and culturally challenging.

As a transition to the future of healthcare, Dr. Morrison reviewed the concept of “the second curve” in business. Most hospitals have mastered the first curve of volume-based care, which is daily business and operations. The second curve, which is more value-based care, is a new way of doing business. Individual hospitals and healthcare systems must plan for, and succeed with, the second curve to survive. Dr. Morrison said this pressure on the healthcare system and the second curve is real, stating, “We turned the corner and we ain’t going back.”

Public purchasers will continue to play a growing role in the future. Dr. Morrison explained why Medicare Advantage is so resilient. Public employers have huge retiree health benefit problems. Dr. Morrison predicts that public payers will be more dominant by 2020 and public exchanges will grow after a rocky start.

Even with a disruptive start to the healthcare exchanges, Dr. Morrison encouraged the audience to think of the long-term benefits of the healthcare system changes.

He envisions four scenarios for the exchanges:

1. Managed competition nirvana. In this system, both public and private exchanges can grow;

2. Minor miracle. This is where the system is now at the start of exchanges;

3. Single-payer system. This would enable public exchanges to continue to grow and succeed; and

4. Meltdown, caused by patient- and system-risk or politics.

The work of the future is the transformation of the delivery system. This difficult work includes the centrality of clinical integration, information technology, “learning to live on Medicare”, managing a business model migration (from curve 1 to 2), and finally, building a culture of quality and accountability.

Dr. Morrison ended this enlightening session with several ACA implications and roles for hospitalists:

1. Take the long view. This is an area where hospitalists can continue to be leaders;

 

2. Redesign acute care, with hospitalists taking the lead;

3. Reach out beyond the walls. It will be very important for hospitalists to work even more closely with primary care providers;

4. Bring your clinical colleagues along to pursue the “triple aim” (better health, better healthcare, and lower per capita costs); and

5. Benefit patients, payers and providers through these changes.

Key points:

• “We’ve got to change the delivery system;”

• The changes in the healthcare system are areas in which hospitalists can continue to be leaders;

• ACA changes can be better for the patient, payer and provider; and

• HM14 is off to a strong start with a clear, overarching goal of hospitalists leading the changing world of medicine.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

A Scot who describes himself as a “professional futurist,” Ian Morrison, MD, helped HM14 get off to a start with laughter. Describing the background of the changes leading to the Affordable Care Act (ACA), Dr. Morrison repeated his key point several times: “We’ve got to change the delivery system.”

This overview is very timely as the deadline for enrollment to comply with the Affordable Care Act is March 31, 2014. Dr. Morrison cited that as of March 11, more than five million Americans have enrolled in exchanges and over 80% of them have paid premiums. Up to 14 million Americans are eligible for Medicaid expansion programs. It is unknown how many of these people were previously uninsured.

Dr. Morrison described several key current issues, including:

1. There are “two Americas”—those states expanding Medicaid and those states declining any expansion;

2. The ACA is the “the Law of the Land.” The difficult task is now implementing this large change in the industry;

3. Accountable Care is a megatrend, but accountable care organizations may not continue in the form they are now;

4. Pressure on costs and delivering value is intensifying;

5. Medicare is still a major part of the healthcare system. “Learning to live in Medicare” means taking out 10% to 20% of costs; and

6. There is a renewed focus on primary care.

Dr. Morrison shared a vision of the future as these trends continue. There will continue to be “massive consolidation” in which there may be only 100-200 large regional healthcare systems in the U.S. Related to this linked care, clinical protocols will be more widely used. Care coordination of transitions will be at a premium. The transition of moving away from hospital admissions to more home care will be economically and culturally challenging.

As a transition to the future of healthcare, Dr. Morrison reviewed the concept of “the second curve” in business. Most hospitals have mastered the first curve of volume-based care, which is daily business and operations. The second curve, which is more value-based care, is a new way of doing business. Individual hospitals and healthcare systems must plan for, and succeed with, the second curve to survive. Dr. Morrison said this pressure on the healthcare system and the second curve is real, stating, “We turned the corner and we ain’t going back.”

Public purchasers will continue to play a growing role in the future. Dr. Morrison explained why Medicare Advantage is so resilient. Public employers have huge retiree health benefit problems. Dr. Morrison predicts that public payers will be more dominant by 2020 and public exchanges will grow after a rocky start.

Even with a disruptive start to the healthcare exchanges, Dr. Morrison encouraged the audience to think of the long-term benefits of the healthcare system changes.

He envisions four scenarios for the exchanges:

1. Managed competition nirvana. In this system, both public and private exchanges can grow;

2. Minor miracle. This is where the system is now at the start of exchanges;

3. Single-payer system. This would enable public exchanges to continue to grow and succeed; and

4. Meltdown, caused by patient- and system-risk or politics.

The work of the future is the transformation of the delivery system. This difficult work includes the centrality of clinical integration, information technology, “learning to live on Medicare”, managing a business model migration (from curve 1 to 2), and finally, building a culture of quality and accountability.

Dr. Morrison ended this enlightening session with several ACA implications and roles for hospitalists:

1. Take the long view. This is an area where hospitalists can continue to be leaders;

 

2. Redesign acute care, with hospitalists taking the lead;

3. Reach out beyond the walls. It will be very important for hospitalists to work even more closely with primary care providers;

4. Bring your clinical colleagues along to pursue the “triple aim” (better health, better healthcare, and lower per capita costs); and

5. Benefit patients, payers and providers through these changes.

Key points:

• “We’ve got to change the delivery system;”

• The changes in the healthcare system are areas in which hospitalists can continue to be leaders;

• ACA changes can be better for the patient, payer and provider; and

• HM14 is off to a strong start with a clear, overarching goal of hospitalists leading the changing world of medicine.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

A Scot who describes himself as a “professional futurist,” Ian Morrison, MD, helped HM14 get off to a start with laughter. Describing the background of the changes leading to the Affordable Care Act (ACA), Dr. Morrison repeated his key point several times: “We’ve got to change the delivery system.”

This overview is very timely as the deadline for enrollment to comply with the Affordable Care Act is March 31, 2014. Dr. Morrison cited that as of March 11, more than five million Americans have enrolled in exchanges and over 80% of them have paid premiums. Up to 14 million Americans are eligible for Medicaid expansion programs. It is unknown how many of these people were previously uninsured.

Dr. Morrison described several key current issues, including:

1. There are “two Americas”—those states expanding Medicaid and those states declining any expansion;

2. The ACA is the “the Law of the Land.” The difficult task is now implementing this large change in the industry;

3. Accountable Care is a megatrend, but accountable care organizations may not continue in the form they are now;

4. Pressure on costs and delivering value is intensifying;

5. Medicare is still a major part of the healthcare system. “Learning to live in Medicare” means taking out 10% to 20% of costs; and

6. There is a renewed focus on primary care.

Dr. Morrison shared a vision of the future as these trends continue. There will continue to be “massive consolidation” in which there may be only 100-200 large regional healthcare systems in the U.S. Related to this linked care, clinical protocols will be more widely used. Care coordination of transitions will be at a premium. The transition of moving away from hospital admissions to more home care will be economically and culturally challenging.

As a transition to the future of healthcare, Dr. Morrison reviewed the concept of “the second curve” in business. Most hospitals have mastered the first curve of volume-based care, which is daily business and operations. The second curve, which is more value-based care, is a new way of doing business. Individual hospitals and healthcare systems must plan for, and succeed with, the second curve to survive. Dr. Morrison said this pressure on the healthcare system and the second curve is real, stating, “We turned the corner and we ain’t going back.”

Public purchasers will continue to play a growing role in the future. Dr. Morrison explained why Medicare Advantage is so resilient. Public employers have huge retiree health benefit problems. Dr. Morrison predicts that public payers will be more dominant by 2020 and public exchanges will grow after a rocky start.

Even with a disruptive start to the healthcare exchanges, Dr. Morrison encouraged the audience to think of the long-term benefits of the healthcare system changes.

He envisions four scenarios for the exchanges:

1. Managed competition nirvana. In this system, both public and private exchanges can grow;

2. Minor miracle. This is where the system is now at the start of exchanges;

3. Single-payer system. This would enable public exchanges to continue to grow and succeed; and

4. Meltdown, caused by patient- and system-risk or politics.

The work of the future is the transformation of the delivery system. This difficult work includes the centrality of clinical integration, information technology, “learning to live on Medicare”, managing a business model migration (from curve 1 to 2), and finally, building a culture of quality and accountability.

Dr. Morrison ended this enlightening session with several ACA implications and roles for hospitalists:

1. Take the long view. This is an area where hospitalists can continue to be leaders;

 

2. Redesign acute care, with hospitalists taking the lead;

3. Reach out beyond the walls. It will be very important for hospitalists to work even more closely with primary care providers;

4. Bring your clinical colleagues along to pursue the “triple aim” (better health, better healthcare, and lower per capita costs); and

5. Benefit patients, payers and providers through these changes.

Key points:

• “We’ve got to change the delivery system;”

• The changes in the healthcare system are areas in which hospitalists can continue to be leaders;

• ACA changes can be better for the patient, payer and provider; and

• HM14 is off to a strong start with a clear, overarching goal of hospitalists leading the changing world of medicine.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

Presenter: Maria Finnell, MD

Summation: Dr. Finnell reviewed in detail the recommendations and controversies surrounding the revised 2011 guidelines. The thrust was on more refined diagnostic criteria and rigorous review of diagnostic options (ultrasound, VCUG) and therapeutic options (length of treatment, IV vs oral antibiotics, and prophylactic therapy).

Key Takeaways

1. The diagnosis of a UTI is based on an abnormal urinalysis and a positive urine culture, now defined as >50,000 CFU/ml. A bag-colleted urine is not very effective in truly diagnosing a UTI (due to excessive false positives).
2. Oral treatment is as effective as IV therapy.
3. Duration of 7-14 days is recommended. There is not definitive evidence to support a more specific length at this time.
4. A VCUG is not recommended after a 1st febrile UTI for children 2 months- 2 years of age.
5. Antibiotic prophylaxis does increase antibiotic resistance and is not clearly helpful for reflux grades 1-2. For reflux grades 3-5, it may still be effective.
6. Educating parents of children who have had a 1st febrile UTI to arrange for early evaluation of a possible secondary febrile UTIs is key in catching UTIs early.

Dr. Harlan is a pediatric hospitalist, medical director with IPC The Hospitalist Company, and member of Team Hospitalist.

 

Presenter: Maria Finnell, MD

Summation: Dr. Finnell reviewed in detail the recommendations and controversies surrounding the revised 2011 guidelines. The thrust was on more refined diagnostic criteria and rigorous review of diagnostic options (ultrasound, VCUG) and therapeutic options (length of treatment, IV vs oral antibiotics, and prophylactic therapy).

Key Takeaways

1. The diagnosis of a UTI is based on an abnormal urinalysis and a positive urine culture, now defined as >50,000 CFU/ml. A bag-colleted urine is not very effective in truly diagnosing a UTI (due to excessive false positives).
2. Oral treatment is as effective as IV therapy.
3. Duration of 7-14 days is recommended. There is not definitive evidence to support a more specific length at this time.
4. A VCUG is not recommended after a 1st febrile UTI for children 2 months- 2 years of age.
5. Antibiotic prophylaxis does increase antibiotic resistance and is not clearly helpful for reflux grades 1-2. For reflux grades 3-5, it may still be effective.
6. Educating parents of children who have had a 1st febrile UTI to arrange for early evaluation of a possible secondary febrile UTIs is key in catching UTIs early.

Dr. Harlan is a pediatric hospitalist, medical director with IPC The Hospitalist Company, and member of Team Hospitalist.

 

Presenter: Maria Finnell, MD

Summation: Dr. Finnell reviewed in detail the recommendations and controversies surrounding the revised 2011 guidelines. The thrust was on more refined diagnostic criteria and rigorous review of diagnostic options (ultrasound, VCUG) and therapeutic options (length of treatment, IV vs oral antibiotics, and prophylactic therapy).

Key Takeaways

1. The diagnosis of a UTI is based on an abnormal urinalysis and a positive urine culture, now defined as >50,000 CFU/ml. A bag-colleted urine is not very effective in truly diagnosing a UTI (due to excessive false positives).
2. Oral treatment is as effective as IV therapy.
3. Duration of 7-14 days is recommended. There is not definitive evidence to support a more specific length at this time.
4. A VCUG is not recommended after a 1st febrile UTI for children 2 months- 2 years of age.
5. Antibiotic prophylaxis does increase antibiotic resistance and is not clearly helpful for reflux grades 1-2. For reflux grades 3-5, it may still be effective.
6. Educating parents of children who have had a 1st febrile UTI to arrange for early evaluation of a possible secondary febrile UTIs is key in catching UTIs early.

Dr. Harlan is a pediatric hospitalist, medical director with IPC The Hospitalist Company, and member of Team Hospitalist.

 

Presenter: Maria Finnell, M.D., a leading member of the American Academy of Pediatrics Subcommittee on Urinary Tract Infection

Summary: Dr. Finnell summarized the recent changes in diagnosis and management of pediatric urinary tract infections (UTIs). The 2011 publication of “Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months” was an update of the 1999 technical report of UTI management. Dr. Finnell reviewed the difference between evidence based and eminence based recommendations. She stated the term “recommendations” was changed to “key action statements” in a new explicit reporting format. Aggregate quality of the evidence is presented in the report in an effort to keep statements transparent.

The process of updating the new guideline was based on the U.S. Preventive Services Task Force approach using a stepwise process. For the revised UTI recommendations the steps were narrowed to:

• Risk of having infection
• Making a diagnosis
• Treatment of UTI
• Identification and Evaluation for high risk conditions

Patient population for this guideline includes initial UTI in child age 2 months to 2 years of age. Patients with neurological conditions or recurrent UTI or renal damage are excluded. Dr. Finnell reviewed action statements for the revised guidelines. A summary of some of these statements:

1. If antibiotics are going to be administered, a urine specimen should be collected by catheterization or suprapubic aspiration (SPA).
2. Assessment of UTI risk should be performed in a febrile child with no source of infection. The guideline cites specific data for risk. If the likelihood is low then it is reasonable to follow the child clinically without a urine specimen. If the likelihood of a UTI is high then a urine specimen should be obtained.
3. To establish the diagnosis of UTI, clinicians should require both urinalysis results that suggest infection and the presence of at least 50,000 colony-forming units (CFUs) per mL of a uropathogen cultured from a urine specimen obtained through catheterization or SPA.
4. Oral and parenteral routes are equally efficacious.
5. The clinician should choose 7-14 days as duration of treatment.
6. Febrile infants with UTIs should undergo renal and bladder ultrasonography.
7. VCUG should not be routinely performed after first UTI if ultrasound is normal.

Dr. Finnell also discussed controversy of not performing a VCUG after a first febrile UTI, as was recommended in the 1999 technical report. She summarized that about 100 children would need to undergo one UTI in the first year. She also reviewed limitations of any guidelines. New studies will assist in monitoring population changes with the revised guideline.

Key Takeaways:

• Understand the evidence and limitations used for all clinical guidelines that you use in practice.
• The updated 2011 guideline for evaluation and management of first febrile UTIs uses risk stratification as an initial approach.
•  A major change in the updated 2011 guideline for evaluation and management of first febrile UTIs is that a VCUG is not required for initial evaluation.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

Reference:

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. 2011;128(3).

 

 

Presenter: Maria Finnell, M.D., a leading member of the American Academy of Pediatrics Subcommittee on Urinary Tract Infection

Summary: Dr. Finnell summarized the recent changes in diagnosis and management of pediatric urinary tract infections (UTIs). The 2011 publication of “Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months” was an update of the 1999 technical report of UTI management. Dr. Finnell reviewed the difference between evidence based and eminence based recommendations. She stated the term “recommendations” was changed to “key action statements” in a new explicit reporting format. Aggregate quality of the evidence is presented in the report in an effort to keep statements transparent.

The process of updating the new guideline was based on the U.S. Preventive Services Task Force approach using a stepwise process. For the revised UTI recommendations the steps were narrowed to:

• Risk of having infection
• Making a diagnosis
• Treatment of UTI
• Identification and Evaluation for high risk conditions

Patient population for this guideline includes initial UTI in child age 2 months to 2 years of age. Patients with neurological conditions or recurrent UTI or renal damage are excluded. Dr. Finnell reviewed action statements for the revised guidelines. A summary of some of these statements:

1. If antibiotics are going to be administered, a urine specimen should be collected by catheterization or suprapubic aspiration (SPA).
2. Assessment of UTI risk should be performed in a febrile child with no source of infection. The guideline cites specific data for risk. If the likelihood is low then it is reasonable to follow the child clinically without a urine specimen. If the likelihood of a UTI is high then a urine specimen should be obtained.
3. To establish the diagnosis of UTI, clinicians should require both urinalysis results that suggest infection and the presence of at least 50,000 colony-forming units (CFUs) per mL of a uropathogen cultured from a urine specimen obtained through catheterization or SPA.
4. Oral and parenteral routes are equally efficacious.
5. The clinician should choose 7-14 days as duration of treatment.
6. Febrile infants with UTIs should undergo renal and bladder ultrasonography.
7. VCUG should not be routinely performed after first UTI if ultrasound is normal.

Dr. Finnell also discussed controversy of not performing a VCUG after a first febrile UTI, as was recommended in the 1999 technical report. She summarized that about 100 children would need to undergo one UTI in the first year. She also reviewed limitations of any guidelines. New studies will assist in monitoring population changes with the revised guideline.

Key Takeaways:

• Understand the evidence and limitations used for all clinical guidelines that you use in practice.
• The updated 2011 guideline for evaluation and management of first febrile UTIs uses risk stratification as an initial approach.
•  A major change in the updated 2011 guideline for evaluation and management of first febrile UTIs is that a VCUG is not required for initial evaluation.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

Reference:

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. 2011;128(3).

 

 

Presenter: Maria Finnell, M.D., a leading member of the American Academy of Pediatrics Subcommittee on Urinary Tract Infection

Summary: Dr. Finnell summarized the recent changes in diagnosis and management of pediatric urinary tract infections (UTIs). The 2011 publication of “Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months” was an update of the 1999 technical report of UTI management. Dr. Finnell reviewed the difference between evidence based and eminence based recommendations. She stated the term “recommendations” was changed to “key action statements” in a new explicit reporting format. Aggregate quality of the evidence is presented in the report in an effort to keep statements transparent.

The process of updating the new guideline was based on the U.S. Preventive Services Task Force approach using a stepwise process. For the revised UTI recommendations the steps were narrowed to:

• Risk of having infection
• Making a diagnosis
• Treatment of UTI
• Identification and Evaluation for high risk conditions

Patient population for this guideline includes initial UTI in child age 2 months to 2 years of age. Patients with neurological conditions or recurrent UTI or renal damage are excluded. Dr. Finnell reviewed action statements for the revised guidelines. A summary of some of these statements:

1. If antibiotics are going to be administered, a urine specimen should be collected by catheterization or suprapubic aspiration (SPA).
2. Assessment of UTI risk should be performed in a febrile child with no source of infection. The guideline cites specific data for risk. If the likelihood is low then it is reasonable to follow the child clinically without a urine specimen. If the likelihood of a UTI is high then a urine specimen should be obtained.
3. To establish the diagnosis of UTI, clinicians should require both urinalysis results that suggest infection and the presence of at least 50,000 colony-forming units (CFUs) per mL of a uropathogen cultured from a urine specimen obtained through catheterization or SPA.
4. Oral and parenteral routes are equally efficacious.
5. The clinician should choose 7-14 days as duration of treatment.
6. Febrile infants with UTIs should undergo renal and bladder ultrasonography.
7. VCUG should not be routinely performed after first UTI if ultrasound is normal.

Dr. Finnell also discussed controversy of not performing a VCUG after a first febrile UTI, as was recommended in the 1999 technical report. She summarized that about 100 children would need to undergo one UTI in the first year. She also reviewed limitations of any guidelines. New studies will assist in monitoring population changes with the revised guideline.

Key Takeaways:

• Understand the evidence and limitations used for all clinical guidelines that you use in practice.
• The updated 2011 guideline for evaluation and management of first febrile UTIs uses risk stratification as an initial approach.
•  A major change in the updated 2011 guideline for evaluation and management of first febrile UTIs is that a VCUG is not required for initial evaluation.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

Reference:

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. 2011;128(3).

 

 

Session: HFNC in Bronchiolitis: Best Thing Since Sliced Bread?

Presenter: Shawn Ralston, MD

Summation: Shawn Ralston, known as “Dr. Bronchiolitis” for her work on the AAP Bronchiolitis Practice Guideline, described the limited data on the use of High Flow Nasal Cannula (HFNC) in bronchiolitis. For HFNC to be effective it must have a flow above the patient’s minute ventilation, or at least 2 LPM for the infant. Physiologic studies show that HFNC improve work of breathing by washing out dead space and providing “mini-CPAP.” Increasing flow increases the CPAP effect up to about 6 LPM with less effect at higher rates. HFNC can achieve equivalent CPAP levels of about 3-4, with higher flows increasing pneumothorax risk. Studies of HFNC in bronchiolitis have been observational and retrospective showing trends towards decrease risk of intubation and that HFNC can be safely used outside an ICU setting. There are no clear data or guidelines to indicate which patients with bronchiolitis will benefit from HFNC.

Key Points:

• Need cannula at least 50% diameter of nares;
• Mouth should be closed—can use pacifier;
• Need flow rate above estimated minute ventilation;
• Higher flow, increase pneumothorax risk;
• Need high quality studies to better understand the role of HFNC in bronchiolitis.

David Pressel is a Pediatric Hospitalist and Inpatient Medical Director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, DE and a member of Team Hospitalist.

Session: HFNC in Bronchiolitis: Best Thing Since Sliced Bread?

Presenter: Shawn Ralston, MD

Summation: Shawn Ralston, known as “Dr. Bronchiolitis” for her work on the AAP Bronchiolitis Practice Guideline, described the limited data on the use of High Flow Nasal Cannula (HFNC) in bronchiolitis. For HFNC to be effective it must have a flow above the patient’s minute ventilation, or at least 2 LPM for the infant. Physiologic studies show that HFNC improve work of breathing by washing out dead space and providing “mini-CPAP.” Increasing flow increases the CPAP effect up to about 6 LPM with less effect at higher rates. HFNC can achieve equivalent CPAP levels of about 3-4, with higher flows increasing pneumothorax risk. Studies of HFNC in bronchiolitis have been observational and retrospective showing trends towards decrease risk of intubation and that HFNC can be safely used outside an ICU setting. There are no clear data or guidelines to indicate which patients with bronchiolitis will benefit from HFNC.

Key Points:

• Need cannula at least 50% diameter of nares;
• Mouth should be closed—can use pacifier;
• Need flow rate above estimated minute ventilation;
• Higher flow, increase pneumothorax risk;
• Need high quality studies to better understand the role of HFNC in bronchiolitis.

David Pressel is a Pediatric Hospitalist and Inpatient Medical Director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, DE and a member of Team Hospitalist.

Session: HFNC in Bronchiolitis: Best Thing Since Sliced Bread?

Presenter: Shawn Ralston, MD

Summation: Shawn Ralston, known as “Dr. Bronchiolitis” for her work on the AAP Bronchiolitis Practice Guideline, described the limited data on the use of High Flow Nasal Cannula (HFNC) in bronchiolitis. For HFNC to be effective it must have a flow above the patient’s minute ventilation, or at least 2 LPM for the infant. Physiologic studies show that HFNC improve work of breathing by washing out dead space and providing “mini-CPAP.” Increasing flow increases the CPAP effect up to about 6 LPM with less effect at higher rates. HFNC can achieve equivalent CPAP levels of about 3-4, with higher flows increasing pneumothorax risk. Studies of HFNC in bronchiolitis have been observational and retrospective showing trends towards decrease risk of intubation and that HFNC can be safely used outside an ICU setting. There are no clear data or guidelines to indicate which patients with bronchiolitis will benefit from HFNC.

Key Points:

• Need cannula at least 50% diameter of nares;
• Mouth should be closed—can use pacifier;
• Need flow rate above estimated minute ventilation;
• Higher flow, increase pneumothorax risk;
• Need high quality studies to better understand the role of HFNC in bronchiolitis.

David Pressel is a Pediatric Hospitalist and Inpatient Medical Director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, DE and a member of Team Hospitalist.

CASE Self Signing
Mrs. H, a 47-year-old, deaf, African American woman, is brought into the emergency room because she is becoming increasingly withdrawn and is signing to herself. She was hospitalized more than 10 years ago after de­veloping psychotic symptoms and received a diagnosis of psychotic disorder, not otherwise specified. She was treated with olanzapine, 10 mg/d, and valproic acid, 1,000 mg/d, but she has not seen a psychiatrist or taken any psy­chotropics in 8 years. Upon admission to the inpatient psychiatric unit, Mrs. H reports, through an American Sign Language (ASL) interpreter, that she has had “problems with her parents” and with “being fair” and that she is 18 months pregnant. Urine pregnancy test is negative. Mrs. H also reports that her mother is pregnant. She indicates that it is difficult for her to describe what she is try­ing to say and that it is difficult to be deaf. 

She endorses “very strong” racing thoughts, which she first states have been present for 15 years, then reports it has been 20 months. She endorses high-energy levels, feeling like there is “work to do,” and poor sleep. However, when asked, she indicates that she sleeps for 15 hours a day.

Which is critical when conducting a psychiatric assessment for a deaf patient?

   a) rely only on the ASL interpreter
   b) inquire about the patient’s communica­tion preferences
   c) use written language to communicate instead of speech
   d) use a family member as interpreter

The authors’ observations
Mental health assessment of a deaf a patient involves a unique set of challenges and requires a specialized skill set for mental health practitioners—a skill set that is not routinely covered in psychiatric training programs.

a We use the term “deaf” to describe patients who have severe hearing loss. Other terms, such as “hearing impaired,” might be considered pejorative in the Deaf community. The term “Deaf” (capitalized) refers to Deaf culture and community, which deaf patients may or may not identify with.

Deafness history
It is important to assess the cause of deafness,^1,2 if known, and its age of onset (Table 1). A person is considered to be pre­lingually deaf if hearing loss was diagnosed before age 3.² Clinicians should establish the patient’s communication preferences (use of assistive devices or interpreters or preference for lip reading), home commu­nication dynamic,² and language fluency level.^1-3 Ask the patient if she attended a specialized school for the deaf and, if so, if there was an emphasis on oral communica­tion or signing.²

HISTORY Conflicting reports
Mrs. H reports that she has been deaf since age 9, and that she learned sign language in India, where she became the “star king.” Mrs. H states that she then moved to the United States where she went to a school for the deaf. When asked if her family is able to communicate with her in sign language, she nods and indicates that they speak to her in “African and Indian.”

Mrs. H’s husband, who is hearing, says that Mrs. H is congenitally deaf, and was raised in the Midwestern United States where she at­tended a specialized school for the deaf. Mr. H and his 2 adult sons are hearing but commu­nicate with Mrs. H in basic ASL. He states that Mrs. H sometimes uses signs that he and his sons cannot interpret. In addition to increased self-preoccupation and self-signing, Mrs. H has become more impulsive.

What are limitations of the mental status examination when evaluating a deaf patient?

   a) facial expressions have a specific linguis­tic function in ASL
   b) there is no differentiation in the mental status exam of deaf patients from that of hearing patients
   c) the Mini-Mental State Examination (MMSE) is a validated tool to assess cogni­tion in deaf patients
   d) the clinician should not rely on the in­terpreter to assist with the mental status examination

The authors’ observation
Performing a mental status examination of a deaf patient without recognizing some of the challenges inherent to this task can lead to misleading findings. For example, sign­ing and gesturing can give the clinician an impression of psychomotor agitation.² What appears to be socially withdrawn behavior might be a reaction to the patient’s inability to communicate with others.^2,3 Social skills may be affected by language deprivation, if present.³ In ASL, facial expressions have specific linguistic functions in addition to representing emotions,² and can affect the meaning of the sign used. An exaggerated or intense facial expression with the sign “quiet,” for example, usually means “very quiet.”⁴ In assessing cognition, the MMSE is not available in ASL and has not been vali­dated in deaf patients.⁵ Also, deaf people have reduced access to information, and a lack of knowledge does not necessarily cor­relate with low IQ.²

 

The interpreter’s role
An ASL interpreter can aid in assessing a deaf patient’s communication skills. The interpreter can help with a thorough lan­guage evaluation^1,6 and provide information about socio-cultural norms in the Deaf community.⁷ Using an ASL interpreter with special training in mental health^1,3,6,7 is im­portant to accurately diagnose thought dis­orders in deaf patients.¹

EVALUATION Mental status exam
Mrs. H is poorly groomed and is wearing a pink housecoat, with her hair in disarray. She seems to be distracted by something next to the in­terpreter, because her eyes keep roving in this direction. She has moderate psychomotor agi­tation, based on the rapidity of her signing and gesturing. Mrs. H makes indecipherable vocal­izations while signing, often loud and with an urgent quality. Her affect is elevated and ex­pansive. She is not oriented to place or time and when asked where she is, signs, “many times, every day, 6-9-9, 2-5, more trouble…”

The ASL interpreter notes that Mrs. H signs so quickly that only about one-half of her signs are interpretable. Mrs. H’s grammar is not always correct and that her syntax is, at times, inappro­priate. Mrs. H’s letters are difficult to interpret because she often starts and concludes a word with a clear sign, but the intervening letters are rapid and uninterpretable. She also uses several non-alphabet signs that cannot be in­terpreted (approximately 10% to 15% of signs) and repeats signs without clear context, such as “nothing off.” Mrs. H can pause to clarify for the interpreter at the beginning of the interview but is not able to do so by the end of the interview.

How does assessment of psychosis differ when evaluating deaf patients?

   a) language dysfluency must be carefully differentiated from a thought disorder
   b) signing to oneself does not necessarily indicate a response to internal stimuli
   c) norms in Deaf culture might be miscon­strued as delusions
   d) all of the above

The authors’ observations
The prevalence of psychotic disorders among deaf patients is unknown.⁸ Although older studies have reported an increased prevalence of psychotic disorders among deaf patients, these studies suffer from methodological problems.¹ Other studies are at odds with each other, variably reporting a greater,⁹ equivalent,¹⁰ and lesser incidence of psychotic disorders in deaf psychiatric in­patients.¹¹ Deaf patients with psychotic dis­orders experience delusions, hallucinations, and thought disorders,^1,3 and assessing for these symptoms in deaf patients can present a diagnostic challenge (Table 2).

Delusions are thought to present simi­larly in deaf patients with psychotic dis­orders compared with hearing patients.^1,3 Paranoia may be increased in patients who are postlingually deaf, but has not been as­sociated with prelingual deafness. Deficits in theory of mind related to hearing im­pairment have been thought to contribute to delusions in deaf patients.^1,12

Many deaf patients distrust health care systems and providers,^2,3,13 which may be misinterpreted as paranoia. Poor commu­nication between deaf patients and clini­cians and poor health literacy among deaf patients contribute to feelings of mistrust. Deaf patients often report experiencing prejudice within the health care system, and think that providers lack sufficient knowledge of deafness.¹³ Care must be taken to ensure that Deaf cultural norms are not misinterpreted as delusions.

Hallucinations. How deaf patients expe­rience hallucinations, especially in prelingual deafness, likely is different from hallucinatory experiences of hearing patients.^1,14 Deaf people with psychosis have described ”ideas coming into one’s head” and an almost “telepathic” process of “knowing.”¹⁴ Deaf patients with schizo­phrenia are more likely to report visual elements to their hallucinations; however, these may be subvisual precepts rather than true visual hallucinations.^1,15 For ex­ample, hallucination might include the perception of being signed to.¹

Deaf patients’ experience of auditory hallucinations is thought to be closely re­lated to past auditory experiences. It is unlikely that prelingually deaf patients experience true auditory hallucinations.^1,14 An endorsement of hearing a “voice” in ASL does not necessarily translate to an audiological experience.¹⁵ If profoundly prelingually deaf patients endorse hearing voices, generally they cannot assign acous­tic properties (pitch, tone, volume, accent, etc.).^1,14,15 It may not be necessary to fully comprehend the precise modality of how hallucinations are experienced by deaf pa­tients to provide therapy.¹⁴

Self-signing, or signing to oneself, does not necessarily indicate that a deaf person is responding to a hallucinatory experience. Non-verbal patients may gesture to them­selves without clear evidence of psychosis. When considering whether a patient is ex­periencing hallucinations, it is important to look for other evidence of psychosis.³

Possible approaches to evaluating hal­lucinations in deaf patients include ask­ing,, “is someone signing in your head?” or “Is someone who is not in the room trying to communicate with you?”

 

Thought disorders in deaf psychiatric in­patients are difficult to diagnose, in part because of a high rate of language dysflu­ency in deaf patients; in samples of psychi­atric inpatients, 75% are not fluent in ASL, 66% are not fluent in any language).^1,3,11 Commonly, language dysfluency is related to language deprivation because of late or inadequate exposure to ASL, although it may be related to neurologic damage or aphasia.^1,3,6,16 Deaf patients can have addi­tional disabilities, including learning dis­abilities, that might contribute to language dysfluency.² Language dysfluency can be misattributed to a psychotic process^1-3,7 (Table 3).¹

Language dysfluency and thought dis­orders can be difficult to differentiate and may be comorbid. Loose associations and flight of ideas can be hard to assess in pa­tients with language dysfluency. In general, increasing looseness of association between concepts corresponds to an increasing like­lihood that a patient has true loose asso­ciations rather than language dysfluency alone.³ Deaf patients with schizophrenia can be identified by the presence of associ­ated symptoms of psychosis, especially if delusions are present.^1,3

EVALUATION Psychotic symptoms
Mrs. H’s thought process appears disorganized and illogical, with flight of ideas. She might have an underlying language dysfluency. It is likely that Mrs. H is using neologisms to communi­cate because of her family’s lack of familiarity with some of her signs. She also demonstrates perseveration, with use of certain signs repeat­edly without clear context (ie, “nothing off”).

Her thought content includes racial themes—she mentions Russia, Germany, and Vietnam without clear context—and delusions of being the “star king” and of being pregnant. She endorses paranoid feelings that people on the inpatient unit are trying to hurt her, al­though it isn’t clear whether this represents a true paranoid delusion because of the hectic climate of the unit, and she did not show unnecessarily defensive or guarded behaviors.

She is seen signing to herself in the dayroom and endorses feeling as though someone who is not in the room—described as an Indian teacher (and sometimes as a boss or principal) known as “Mr. Smith” or “Mr. Donald”—is trying to communicate with her. She describes this person as being male and female. She men­tions that sometimes she sees an Indian man and another man fighting. It is likely that Mrs. H is experiencing hallucinations from decompen­sated psychosis, because of the constellation and trajectory of her symptoms. Her nonverbal behavior—her eyes rove around the room dur­ing interviews—also supports this conclusion.

Because of evidence of mood and psychotic symptoms, and with a collateral history that suggests significant baseline disorganization, Mrs. H receives a diagnosis of schizoaffective disorder, bipolar type. She is restarted on olan­zapine, 10 mg/d, and valproic acid, 1,000 mg/d.

Mrs. H’s psychomotor acceleration and af­fective elevation gradually improve with phar­macotherapy. After a 2-week hospitalization, despite ongoing disorganization and self-sign­ing, Mrs. H’s husband says that he feels she is improved enough to return home, with plans to continue to take her medications and to re­establish outpatient follow-up.

Bottom Line

Psychiatric assessment of deaf patients presents distinctive challenges related to cultural and language barriers—making it important to engage an ASL interpreter with training in mental health during assessment of a deaf patient. Clinicians must become familiar with these challenges to provide effective care for mentally ill deaf patients.

Related Resources
• Landsberger SA, Diaz DR. Communicating with deaf pa­tients: 10 tips to deliver appropriate care. Current Psychiatry. 2010;9(6):36-37.
• Deaf Wellness Center. University of Rochester School of Medicine. www.urmc.rochester.edu/deaf-wellness-center.
• Gallaudet University Mental Health Center. www.gallaudet.edu/
mental_health_center.html.

Drug Brand Names
Olanzapine • Zyprexa
Valproic acid • Depakote

Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE Self Signing
Mrs. H, a 47-year-old, deaf, African American woman, is brought into the emergency room because she is becoming increasingly withdrawn and is signing to herself. She was hospitalized more than 10 years ago after de­veloping psychotic symptoms and received a diagnosis of psychotic disorder, not otherwise specified. She was treated with olanzapine, 10 mg/d, and valproic acid, 1,000 mg/d, but she has not seen a psychiatrist or taken any psy­chotropics in 8 years. Upon admission to the inpatient psychiatric unit, Mrs. H reports, through an American Sign Language (ASL) interpreter, that she has had “problems with her parents” and with “being fair” and that she is 18 months pregnant. Urine pregnancy test is negative. Mrs. H also reports that her mother is pregnant. She indicates that it is difficult for her to describe what she is try­ing to say and that it is difficult to be deaf. 

She endorses “very strong” racing thoughts, which she first states have been present for 15 years, then reports it has been 20 months. She endorses high-energy levels, feeling like there is “work to do,” and poor sleep. However, when asked, she indicates that she sleeps for 15 hours a day.

Which is critical when conducting a psychiatric assessment for a deaf patient?

   a) rely only on the ASL interpreter
   b) inquire about the patient’s communica­tion preferences
   c) use written language to communicate instead of speech
   d) use a family member as interpreter

The authors’ observations
Mental health assessment of a deaf a patient involves a unique set of challenges and requires a specialized skill set for mental health practitioners—a skill set that is not routinely covered in psychiatric training programs.

a We use the term “deaf” to describe patients who have severe hearing loss. Other terms, such as “hearing impaired,” might be considered pejorative in the Deaf community. The term “Deaf” (capitalized) refers to Deaf culture and community, which deaf patients may or may not identify with.

Deafness history
It is important to assess the cause of deafness,^1,2 if known, and its age of onset (Table 1). A person is considered to be pre­lingually deaf if hearing loss was diagnosed before age 3.² Clinicians should establish the patient’s communication preferences (use of assistive devices or interpreters or preference for lip reading), home commu­nication dynamic,² and language fluency level.^1-3 Ask the patient if she attended a specialized school for the deaf and, if so, if there was an emphasis on oral communica­tion or signing.²

HISTORY Conflicting reports
Mrs. H reports that she has been deaf since age 9, and that she learned sign language in India, where she became the “star king.” Mrs. H states that she then moved to the United States where she went to a school for the deaf. When asked if her family is able to communicate with her in sign language, she nods and indicates that they speak to her in “African and Indian.”

Mrs. H’s husband, who is hearing, says that Mrs. H is congenitally deaf, and was raised in the Midwestern United States where she at­tended a specialized school for the deaf. Mr. H and his 2 adult sons are hearing but commu­nicate with Mrs. H in basic ASL. He states that Mrs. H sometimes uses signs that he and his sons cannot interpret. In addition to increased self-preoccupation and self-signing, Mrs. H has become more impulsive.

What are limitations of the mental status examination when evaluating a deaf patient?

   a) facial expressions have a specific linguis­tic function in ASL
   b) there is no differentiation in the mental status exam of deaf patients from that of hearing patients
   c) the Mini-Mental State Examination (MMSE) is a validated tool to assess cogni­tion in deaf patients
   d) the clinician should not rely on the in­terpreter to assist with the mental status examination

The authors’ observation
Performing a mental status examination of a deaf patient without recognizing some of the challenges inherent to this task can lead to misleading findings. For example, sign­ing and gesturing can give the clinician an impression of psychomotor agitation.² What appears to be socially withdrawn behavior might be a reaction to the patient’s inability to communicate with others.^2,3 Social skills may be affected by language deprivation, if present.³ In ASL, facial expressions have specific linguistic functions in addition to representing emotions,² and can affect the meaning of the sign used. An exaggerated or intense facial expression with the sign “quiet,” for example, usually means “very quiet.”⁴ In assessing cognition, the MMSE is not available in ASL and has not been vali­dated in deaf patients.⁵ Also, deaf people have reduced access to information, and a lack of knowledge does not necessarily cor­relate with low IQ.²

 

The interpreter’s role
An ASL interpreter can aid in assessing a deaf patient’s communication skills. The interpreter can help with a thorough lan­guage evaluation^1,6 and provide information about socio-cultural norms in the Deaf community.⁷ Using an ASL interpreter with special training in mental health^1,3,6,7 is im­portant to accurately diagnose thought dis­orders in deaf patients.¹

EVALUATION Mental status exam
Mrs. H is poorly groomed and is wearing a pink housecoat, with her hair in disarray. She seems to be distracted by something next to the in­terpreter, because her eyes keep roving in this direction. She has moderate psychomotor agi­tation, based on the rapidity of her signing and gesturing. Mrs. H makes indecipherable vocal­izations while signing, often loud and with an urgent quality. Her affect is elevated and ex­pansive. She is not oriented to place or time and when asked where she is, signs, “many times, every day, 6-9-9, 2-5, more trouble…”

The ASL interpreter notes that Mrs. H signs so quickly that only about one-half of her signs are interpretable. Mrs. H’s grammar is not always correct and that her syntax is, at times, inappro­priate. Mrs. H’s letters are difficult to interpret because she often starts and concludes a word with a clear sign, but the intervening letters are rapid and uninterpretable. She also uses several non-alphabet signs that cannot be in­terpreted (approximately 10% to 15% of signs) and repeats signs without clear context, such as “nothing off.” Mrs. H can pause to clarify for the interpreter at the beginning of the interview but is not able to do so by the end of the interview.

How does assessment of psychosis differ when evaluating deaf patients?

   a) language dysfluency must be carefully differentiated from a thought disorder
   b) signing to oneself does not necessarily indicate a response to internal stimuli
   c) norms in Deaf culture might be miscon­strued as delusions
   d) all of the above

The authors’ observations
The prevalence of psychotic disorders among deaf patients is unknown.⁸ Although older studies have reported an increased prevalence of psychotic disorders among deaf patients, these studies suffer from methodological problems.¹ Other studies are at odds with each other, variably reporting a greater,⁹ equivalent,¹⁰ and lesser incidence of psychotic disorders in deaf psychiatric in­patients.¹¹ Deaf patients with psychotic dis­orders experience delusions, hallucinations, and thought disorders,^1,3 and assessing for these symptoms in deaf patients can present a diagnostic challenge (Table 2).

Delusions are thought to present simi­larly in deaf patients with psychotic dis­orders compared with hearing patients.^1,3 Paranoia may be increased in patients who are postlingually deaf, but has not been as­sociated with prelingual deafness. Deficits in theory of mind related to hearing im­pairment have been thought to contribute to delusions in deaf patients.^1,12

Many deaf patients distrust health care systems and providers,^2,3,13 which may be misinterpreted as paranoia. Poor commu­nication between deaf patients and clini­cians and poor health literacy among deaf patients contribute to feelings of mistrust. Deaf patients often report experiencing prejudice within the health care system, and think that providers lack sufficient knowledge of deafness.¹³ Care must be taken to ensure that Deaf cultural norms are not misinterpreted as delusions.

Hallucinations. How deaf patients expe­rience hallucinations, especially in prelingual deafness, likely is different from hallucinatory experiences of hearing patients.^1,14 Deaf people with psychosis have described ”ideas coming into one’s head” and an almost “telepathic” process of “knowing.”¹⁴ Deaf patients with schizo­phrenia are more likely to report visual elements to their hallucinations; however, these may be subvisual precepts rather than true visual hallucinations.^1,15 For ex­ample, hallucination might include the perception of being signed to.¹

Deaf patients’ experience of auditory hallucinations is thought to be closely re­lated to past auditory experiences. It is unlikely that prelingually deaf patients experience true auditory hallucinations.^1,14 An endorsement of hearing a “voice” in ASL does not necessarily translate to an audiological experience.¹⁵ If profoundly prelingually deaf patients endorse hearing voices, generally they cannot assign acous­tic properties (pitch, tone, volume, accent, etc.).^1,14,15 It may not be necessary to fully comprehend the precise modality of how hallucinations are experienced by deaf pa­tients to provide therapy.¹⁴

Self-signing, or signing to oneself, does not necessarily indicate that a deaf person is responding to a hallucinatory experience. Non-verbal patients may gesture to them­selves without clear evidence of psychosis. When considering whether a patient is ex­periencing hallucinations, it is important to look for other evidence of psychosis.³

Possible approaches to evaluating hal­lucinations in deaf patients include ask­ing,, “is someone signing in your head?” or “Is someone who is not in the room trying to communicate with you?”

 

Thought disorders in deaf psychiatric in­patients are difficult to diagnose, in part because of a high rate of language dysflu­ency in deaf patients; in samples of psychi­atric inpatients, 75% are not fluent in ASL, 66% are not fluent in any language).^1,3,11 Commonly, language dysfluency is related to language deprivation because of late or inadequate exposure to ASL, although it may be related to neurologic damage or aphasia.^1,3,6,16 Deaf patients can have addi­tional disabilities, including learning dis­abilities, that might contribute to language dysfluency.² Language dysfluency can be misattributed to a psychotic process^1-3,7 (Table 3).¹

Language dysfluency and thought dis­orders can be difficult to differentiate and may be comorbid. Loose associations and flight of ideas can be hard to assess in pa­tients with language dysfluency. In general, increasing looseness of association between concepts corresponds to an increasing like­lihood that a patient has true loose asso­ciations rather than language dysfluency alone.³ Deaf patients with schizophrenia can be identified by the presence of associ­ated symptoms of psychosis, especially if delusions are present.^1,3

EVALUATION Psychotic symptoms
Mrs. H’s thought process appears disorganized and illogical, with flight of ideas. She might have an underlying language dysfluency. It is likely that Mrs. H is using neologisms to communi­cate because of her family’s lack of familiarity with some of her signs. She also demonstrates perseveration, with use of certain signs repeat­edly without clear context (ie, “nothing off”).

Her thought content includes racial themes—she mentions Russia, Germany, and Vietnam without clear context—and delusions of being the “star king” and of being pregnant. She endorses paranoid feelings that people on the inpatient unit are trying to hurt her, al­though it isn’t clear whether this represents a true paranoid delusion because of the hectic climate of the unit, and she did not show unnecessarily defensive or guarded behaviors.

She is seen signing to herself in the dayroom and endorses feeling as though someone who is not in the room—described as an Indian teacher (and sometimes as a boss or principal) known as “Mr. Smith” or “Mr. Donald”—is trying to communicate with her. She describes this person as being male and female. She men­tions that sometimes she sees an Indian man and another man fighting. It is likely that Mrs. H is experiencing hallucinations from decompen­sated psychosis, because of the constellation and trajectory of her symptoms. Her nonverbal behavior—her eyes rove around the room dur­ing interviews—also supports this conclusion.

Because of evidence of mood and psychotic symptoms, and with a collateral history that suggests significant baseline disorganization, Mrs. H receives a diagnosis of schizoaffective disorder, bipolar type. She is restarted on olan­zapine, 10 mg/d, and valproic acid, 1,000 mg/d.

Mrs. H’s psychomotor acceleration and af­fective elevation gradually improve with phar­macotherapy. After a 2-week hospitalization, despite ongoing disorganization and self-sign­ing, Mrs. H’s husband says that he feels she is improved enough to return home, with plans to continue to take her medications and to re­establish outpatient follow-up.

Bottom Line

Psychiatric assessment of deaf patients presents distinctive challenges related to cultural and language barriers—making it important to engage an ASL interpreter with training in mental health during assessment of a deaf patient. Clinicians must become familiar with these challenges to provide effective care for mentally ill deaf patients.

Related Resources
• Landsberger SA, Diaz DR. Communicating with deaf pa­tients: 10 tips to deliver appropriate care. Current Psychiatry. 2010;9(6):36-37.
• Deaf Wellness Center. University of Rochester School of Medicine. www.urmc.rochester.edu/deaf-wellness-center.
• Gallaudet University Mental Health Center. www.gallaudet.edu/
mental_health_center.html.

Drug Brand Names
Olanzapine • Zyprexa
Valproic acid • Depakote

Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE Self Signing
Mrs. H, a 47-year-old, deaf, African American woman, is brought into the emergency room because she is becoming increasingly withdrawn and is signing to herself. She was hospitalized more than 10 years ago after de­veloping psychotic symptoms and received a diagnosis of psychotic disorder, not otherwise specified. She was treated with olanzapine, 10 mg/d, and valproic acid, 1,000 mg/d, but she has not seen a psychiatrist or taken any psy­chotropics in 8 years. Upon admission to the inpatient psychiatric unit, Mrs. H reports, through an American Sign Language (ASL) interpreter, that she has had “problems with her parents” and with “being fair” and that she is 18 months pregnant. Urine pregnancy test is negative. Mrs. H also reports that her mother is pregnant. She indicates that it is difficult for her to describe what she is try­ing to say and that it is difficult to be deaf. 

She endorses “very strong” racing thoughts, which she first states have been present for 15 years, then reports it has been 20 months. She endorses high-energy levels, feeling like there is “work to do,” and poor sleep. However, when asked, she indicates that she sleeps for 15 hours a day.

Which is critical when conducting a psychiatric assessment for a deaf patient?

   a) rely only on the ASL interpreter
   b) inquire about the patient’s communica­tion preferences
   c) use written language to communicate instead of speech
   d) use a family member as interpreter

The authors’ observations
Mental health assessment of a deaf a patient involves a unique set of challenges and requires a specialized skill set for mental health practitioners—a skill set that is not routinely covered in psychiatric training programs.

a We use the term “deaf” to describe patients who have severe hearing loss. Other terms, such as “hearing impaired,” might be considered pejorative in the Deaf community. The term “Deaf” (capitalized) refers to Deaf culture and community, which deaf patients may or may not identify with.

Deafness history
It is important to assess the cause of deafness,^1,2 if known, and its age of onset (Table 1). A person is considered to be pre­lingually deaf if hearing loss was diagnosed before age 3.² Clinicians should establish the patient’s communication preferences (use of assistive devices or interpreters or preference for lip reading), home commu­nication dynamic,² and language fluency level.^1-3 Ask the patient if she attended a specialized school for the deaf and, if so, if there was an emphasis on oral communica­tion or signing.²

HISTORY Conflicting reports
Mrs. H reports that she has been deaf since age 9, and that she learned sign language in India, where she became the “star king.” Mrs. H states that she then moved to the United States where she went to a school for the deaf. When asked if her family is able to communicate with her in sign language, she nods and indicates that they speak to her in “African and Indian.”

Mrs. H’s husband, who is hearing, says that Mrs. H is congenitally deaf, and was raised in the Midwestern United States where she at­tended a specialized school for the deaf. Mr. H and his 2 adult sons are hearing but commu­nicate with Mrs. H in basic ASL. He states that Mrs. H sometimes uses signs that he and his sons cannot interpret. In addition to increased self-preoccupation and self-signing, Mrs. H has become more impulsive.

What are limitations of the mental status examination when evaluating a deaf patient?

   a) facial expressions have a specific linguis­tic function in ASL
   b) there is no differentiation in the mental status exam of deaf patients from that of hearing patients
   c) the Mini-Mental State Examination (MMSE) is a validated tool to assess cogni­tion in deaf patients
   d) the clinician should not rely on the in­terpreter to assist with the mental status examination

The authors’ observation
Performing a mental status examination of a deaf patient without recognizing some of the challenges inherent to this task can lead to misleading findings. For example, sign­ing and gesturing can give the clinician an impression of psychomotor agitation.² What appears to be socially withdrawn behavior might be a reaction to the patient’s inability to communicate with others.^2,3 Social skills may be affected by language deprivation, if present.³ In ASL, facial expressions have specific linguistic functions in addition to representing emotions,² and can affect the meaning of the sign used. An exaggerated or intense facial expression with the sign “quiet,” for example, usually means “very quiet.”⁴ In assessing cognition, the MMSE is not available in ASL and has not been vali­dated in deaf patients.⁵ Also, deaf people have reduced access to information, and a lack of knowledge does not necessarily cor­relate with low IQ.²

 

The interpreter’s role
An ASL interpreter can aid in assessing a deaf patient’s communication skills. The interpreter can help with a thorough lan­guage evaluation^1,6 and provide information about socio-cultural norms in the Deaf community.⁷ Using an ASL interpreter with special training in mental health^1,3,6,7 is im­portant to accurately diagnose thought dis­orders in deaf patients.¹

EVALUATION Mental status exam
Mrs. H is poorly groomed and is wearing a pink housecoat, with her hair in disarray. She seems to be distracted by something next to the in­terpreter, because her eyes keep roving in this direction. She has moderate psychomotor agi­tation, based on the rapidity of her signing and gesturing. Mrs. H makes indecipherable vocal­izations while signing, often loud and with an urgent quality. Her affect is elevated and ex­pansive. She is not oriented to place or time and when asked where she is, signs, “many times, every day, 6-9-9, 2-5, more trouble…”

The ASL interpreter notes that Mrs. H signs so quickly that only about one-half of her signs are interpretable. Mrs. H’s grammar is not always correct and that her syntax is, at times, inappro­priate. Mrs. H’s letters are difficult to interpret because she often starts and concludes a word with a clear sign, but the intervening letters are rapid and uninterpretable. She also uses several non-alphabet signs that cannot be in­terpreted (approximately 10% to 15% of signs) and repeats signs without clear context, such as “nothing off.” Mrs. H can pause to clarify for the interpreter at the beginning of the interview but is not able to do so by the end of the interview.

How does assessment of psychosis differ when evaluating deaf patients?

   a) language dysfluency must be carefully differentiated from a thought disorder
   b) signing to oneself does not necessarily indicate a response to internal stimuli
   c) norms in Deaf culture might be miscon­strued as delusions
   d) all of the above

The authors’ observations
The prevalence of psychotic disorders among deaf patients is unknown.⁸ Although older studies have reported an increased prevalence of psychotic disorders among deaf patients, these studies suffer from methodological problems.¹ Other studies are at odds with each other, variably reporting a greater,⁹ equivalent,¹⁰ and lesser incidence of psychotic disorders in deaf psychiatric in­patients.¹¹ Deaf patients with psychotic dis­orders experience delusions, hallucinations, and thought disorders,^1,3 and assessing for these symptoms in deaf patients can present a diagnostic challenge (Table 2).

Delusions are thought to present simi­larly in deaf patients with psychotic dis­orders compared with hearing patients.^1,3 Paranoia may be increased in patients who are postlingually deaf, but has not been as­sociated with prelingual deafness. Deficits in theory of mind related to hearing im­pairment have been thought to contribute to delusions in deaf patients.^1,12

Many deaf patients distrust health care systems and providers,^2,3,13 which may be misinterpreted as paranoia. Poor commu­nication between deaf patients and clini­cians and poor health literacy among deaf patients contribute to feelings of mistrust. Deaf patients often report experiencing prejudice within the health care system, and think that providers lack sufficient knowledge of deafness.¹³ Care must be taken to ensure that Deaf cultural norms are not misinterpreted as delusions.

Hallucinations. How deaf patients expe­rience hallucinations, especially in prelingual deafness, likely is different from hallucinatory experiences of hearing patients.^1,14 Deaf people with psychosis have described ”ideas coming into one’s head” and an almost “telepathic” process of “knowing.”¹⁴ Deaf patients with schizo­phrenia are more likely to report visual elements to their hallucinations; however, these may be subvisual precepts rather than true visual hallucinations.^1,15 For ex­ample, hallucination might include the perception of being signed to.¹

Deaf patients’ experience of auditory hallucinations is thought to be closely re­lated to past auditory experiences. It is unlikely that prelingually deaf patients experience true auditory hallucinations.^1,14 An endorsement of hearing a “voice” in ASL does not necessarily translate to an audiological experience.¹⁵ If profoundly prelingually deaf patients endorse hearing voices, generally they cannot assign acous­tic properties (pitch, tone, volume, accent, etc.).^1,14,15 It may not be necessary to fully comprehend the precise modality of how hallucinations are experienced by deaf pa­tients to provide therapy.¹⁴

Self-signing, or signing to oneself, does not necessarily indicate that a deaf person is responding to a hallucinatory experience. Non-verbal patients may gesture to them­selves without clear evidence of psychosis. When considering whether a patient is ex­periencing hallucinations, it is important to look for other evidence of psychosis.³

Possible approaches to evaluating hal­lucinations in deaf patients include ask­ing,, “is someone signing in your head?” or “Is someone who is not in the room trying to communicate with you?”

 

Thought disorders in deaf psychiatric in­patients are difficult to diagnose, in part because of a high rate of language dysflu­ency in deaf patients; in samples of psychi­atric inpatients, 75% are not fluent in ASL, 66% are not fluent in any language).^1,3,11 Commonly, language dysfluency is related to language deprivation because of late or inadequate exposure to ASL, although it may be related to neurologic damage or aphasia.^1,3,6,16 Deaf patients can have addi­tional disabilities, including learning dis­abilities, that might contribute to language dysfluency.² Language dysfluency can be misattributed to a psychotic process^1-3,7 (Table 3).¹

Language dysfluency and thought dis­orders can be difficult to differentiate and may be comorbid. Loose associations and flight of ideas can be hard to assess in pa­tients with language dysfluency. In general, increasing looseness of association between concepts corresponds to an increasing like­lihood that a patient has true loose asso­ciations rather than language dysfluency alone.³ Deaf patients with schizophrenia can be identified by the presence of associ­ated symptoms of psychosis, especially if delusions are present.^1,3

EVALUATION Psychotic symptoms
Mrs. H’s thought process appears disorganized and illogical, with flight of ideas. She might have an underlying language dysfluency. It is likely that Mrs. H is using neologisms to communi­cate because of her family’s lack of familiarity with some of her signs. She also demonstrates perseveration, with use of certain signs repeat­edly without clear context (ie, “nothing off”).

Her thought content includes racial themes—she mentions Russia, Germany, and Vietnam without clear context—and delusions of being the “star king” and of being pregnant. She endorses paranoid feelings that people on the inpatient unit are trying to hurt her, al­though it isn’t clear whether this represents a true paranoid delusion because of the hectic climate of the unit, and she did not show unnecessarily defensive or guarded behaviors.

She is seen signing to herself in the dayroom and endorses feeling as though someone who is not in the room—described as an Indian teacher (and sometimes as a boss or principal) known as “Mr. Smith” or “Mr. Donald”—is trying to communicate with her. She describes this person as being male and female. She men­tions that sometimes she sees an Indian man and another man fighting. It is likely that Mrs. H is experiencing hallucinations from decompen­sated psychosis, because of the constellation and trajectory of her symptoms. Her nonverbal behavior—her eyes rove around the room dur­ing interviews—also supports this conclusion.

Because of evidence of mood and psychotic symptoms, and with a collateral history that suggests significant baseline disorganization, Mrs. H receives a diagnosis of schizoaffective disorder, bipolar type. She is restarted on olan­zapine, 10 mg/d, and valproic acid, 1,000 mg/d.

Mrs. H’s psychomotor acceleration and af­fective elevation gradually improve with phar­macotherapy. After a 2-week hospitalization, despite ongoing disorganization and self-sign­ing, Mrs. H’s husband says that he feels she is improved enough to return home, with plans to continue to take her medications and to re­establish outpatient follow-up.

Bottom Line

Psychiatric assessment of deaf patients presents distinctive challenges related to cultural and language barriers—making it important to engage an ASL interpreter with training in mental health during assessment of a deaf patient. Clinicians must become familiar with these challenges to provide effective care for mentally ill deaf patients.

Related Resources
• Landsberger SA, Diaz DR. Communicating with deaf pa­tients: 10 tips to deliver appropriate care. Current Psychiatry. 2010;9(6):36-37.
• Deaf Wellness Center. University of Rochester School of Medicine. www.urmc.rochester.edu/deaf-wellness-center.
• Gallaudet University Mental Health Center. www.gallaudet.edu/
mental_health_center.html.

Drug Brand Names
Olanzapine • Zyprexa
Valproic acid • Depakote

Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.